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Hyperthermia and Dehydration-Related Deaths Associated with Intentional Rapid Weight Loss in Three Collegiate Wrestlers -- North Carolina, Wisconsin, and Michigan, November-December 1997

During November 7-December 9, 1997, three previously healthy collegiate wrestlers in different states died while each was engaged in a program of rapid weight loss to qualify for competition. In the hours preceding the official weigh-in, all three wrestlers engaged in a similar rapid weight-loss regimen that promoted dehydration through perspiration and resulted in hyperthermia. The wrestlers restricted food and fluid intake and attempted to maximize sweat losses by wearing vapor-impermeable suits under cotton warm-up suits and exercising vigorously in hot environments. This report summarizes the investigation of these three cases. Case Reports

Case 1. During November 6-7, over a 12-hour period, a 19-year-old man in North Carolina attempted to lose 15 lbs to compete in the 195-lb weight class of a wrestling tournament scheduled for November 8. His preseason weight on August 27 was 233 lbs, and during the next 10 weeks he lost 23 lbs. On November 6, from 3 p.m. to 11:30 p.m., using the weight-loss regimen described above, he lost an additional 9 lbs. After a 2-hour rest, he resumed his weight-loss regimen on November 7 at 1:45 a.m. At approximately 2:45 a.m., he stopped exercising but began to experience extreme fatigue and became incommunicative; an hour later, he developed cardiorespiratory arrest. Resuscitation was unsuccessful. Chemistry findings in vitreous humor obtained 7 hours after death were sodium, 152 mmol/L (normal postmortem: 135-151 mmol/L); urea nitrogen, 40 mg/dL (normal postmortem: less than or equal to 40 mg/dL); and urine myoglobin, less than 20 ng/mL (normal antemortem: 0-40 ng/mL); creatinine results were unavailable. Anatomic findings from the autopsy were insufficient to determine the cause of death.

Case 2. On November 21, over a 4-hour period, a 22-year-old man in Wisconsin attempted to lose 4 lbs to compete in the 153-lb weight class of a wrestling tournament scheduled for November 22. His preseason weight on September 6 was 178 lbs. During the next 10 weeks he lost 21 lbs, of which 8 lbs were lost during November 17-20. On November 21 at 5:30 a.m., he initiated the same weight-loss regimen as in case 1. An hour later, he complained of shortness of breath but continued exercising. By 8:50 a.m., he had lost 3.5 lbs. He drank approximately 8 oz of water, rested for 30 minutes, and resumed exercise. At 9:30 a.m., he stopped exercising and indicated he was not feeling well. Efforts were made to cool him, and his clothing was removed. He became unresponsive and developed cardiorespiratory arrest; resuscitation was unsuccessful. Chemistry findings in antemortem blood were serum sodium, 161 mmol/L (normal: 136-145 mmol/L); urea nitrogen, 34 mg/dL (normal: 7-18 mg/dL); and creatinine, 5.0 mg/dL (normal: 0.8-1.3 mg/dL). Serum myoglobin was greater than 5000 ng/mL (normal: 0-110 ng/mL). Rectal temperature was 108 F (42 C) at the time of death. The autopsy report cited the cause of death as hyperthermia.

Case 3. On December 9, over a 3-hour period, a 21-year-old man in Michigan attempted to lose 6 lbs to compete in the 153-lb weight class of a wrestling meet scheduled for December 10. His preseason weight on September 4 was 180 lbs. During the next 13 weeks he lost 21 lbs, of which 11 lbs were lost during December 6-8. On December 9, from 3:30 p.m. to 5 p.m., he lost 2.3 lbs and weighed 156.7 lbs. After wrestling practice, he initiated the same weight-loss regimen as in case 1; after 75 minutes, he had lost an additional 2 lbs. After a 15-minute rest, he resumed exercise. Approximately 1 hour later, he stopped exercising to weigh himself and demonstrated fatigue. A few minutes later, his legs became unsteady, he became incommunicative, and he had difficulty breathing. Attempts to administer fluid orally were unsuccessful, and he developed cardiorespiratory arrest. Resuscitation was unsuccessful. Chemistry findings in vitreous humor obtained 4 hours after death were sodium, 159 mmol/L (normal: 136-146 mmol/L); urea nitrogen, 31 mg/dL (normal: 8-20 mg/dL); and creatinine, 0.7 mg/dL (normal: 0.9-1.3 mg/dL). Urine myoglobin was 4280 ng/mL (normal: 0-45 ng/mL). The autopsy report cited the cause of death as rhabdomyolysis.

Reported by: D Remick, MD, Univ of Michigan, Ann Arbor, Michigan. K Chancellor, MD, North Carolina Dept of Health and Human Svcs. J Pederson, MD, Franciscan Skemp Healthcare, LaCrosse, Wisconsin. EJ Zambraski, PhD, Rutgers Univ, Piscataway, New Jersey. MN Sawka, PhD, CB Wenger, MD, US Army Research Institute of Environmental Medicine, Natick, Massachusetts. Office of Regulatory Affairs; Center for Food Safety and Applied Nutrition, U.S. Food and Drug Administration. Div of Environmental Hazards and Health Effects, National Center for Environmental Health; Div of Nutrition and Physical Activity, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: This report describes the first identified deaths in collegiate wrestling and the first deaths associated with intentional rapid weight loss in interscholastic or collegiate wrestling since national record keeping began in 1982 (1). Many coaches and wrestlers believe that wrestlers should compete at a weight category lower than their preseason weight to maximize their competitive advantage (2,3). To reach their competition weight, many wrestlers achieve rapid weight loss by dehydration through such practices as vigorous exercise, fluid restriction, wearing vapor-impermeable suits, and using hot environments (e.g., saunas, hot rooms, and steam rooms). More extreme but less common measures include consuming diuretics, emetics, and laxatives and self-induced vomiting (2,3). A combination of these practices are often used during the days that precede each competition (4). Alone or in combination, these practices can adversely affect cardiovascular function, electrical activity, thermal regulation, renal function, electrolyte balance, body composition, and muscular endurance and strength (3,5,6).

Vigorous exercise and dehydration increase body temperature, which is further increased by use of vapor-impermeable suits that decrease evaporative and convective heat loss. In the three cases presented in this report, all three wrestlers used vapor-impermeable suits and exercised vigorously in hot environments. These conditions promoted dehydration and heat-related illness (3,5,6). In all three cases, elevated sodium and urea in antemortem blood or postmortem vitreous fluid indicated clear evidence of dehydration. The exercise regimen, the elevated rectal temperature in case 2, and the rhabdomyolysis and myoglobinuria in case 3 indicate that hyperthermia may have contributed to these deaths (6,7).

Among the three wrestlers, the difference between their preseason weight and their goal weight for competition was 30 lbs (range: 25-37 lbs), or approximately 15% of total body weight. Among collegiate wrestlers, the difference between their preseason and competitive weights averages approximately 16 lbs (5), or approximately 10% of total body weight (4). These cases highlight the extreme extent of absolute and relative weight loss. Under such conditions, particularly when dehydration is involved, there are no established limits for safe weight loss.

To ensure fair and safe competition, wrestlers compete within defined weight categories. At the time of these deaths, existing National Collegiate Athletic Association (NCAA) guidelines recommended that the rapid weight-loss behaviors associated with these deaths be prohibited (8). Using practices contrary to the guidelines, all three wrestlers, while under the supervision of athletic staff, attempted to lose unsafe amounts of weight in a short period of time. The findings in the three cases suggest that failure to follow these guidelines may have contributed to these deaths. The weight-loss behaviors reported in these three cases are common among wrestlers; however, deaths associated with weight loss in collegiate wrestling have not been reported previously (1). No information is available to indicate whether the amount or rate of intentional weight loss or other conditioning practices may have changed recently among collegiate wrestlers.

As a result of these deaths, the NCAA revised the guidelines governing weight-loss practices and weigh-in procedures and added penalties for noncompliance (9). The NCAA now prohibits the use of laxatives, emetics, diuretics, excessive food and fluid restriction, self-induced vomiting, hot rooms greater than 79 F (greater than 26 C), hot boxes, saunas, steam rooms, vapor-impermeable suits, and artificial rehydration techniques (e.g., intravenous hydration between weigh-in and competition). In addition, for this season the NCAA has added a 7-lb weight allowance to each weight class, required all wrestlers to compete only in the weight class that they were in as of January 7, and stipulated that all weigh-ins be held no more than 2 hours before the beginning of competition. The NCAA plans to reassess its wrestling policies this spring. The effectiveness of these changes should be monitored and evaluated.

The sudden deterioration and resulting deaths of previously healthy, young, well-trained athletes underscores the need to eliminate weight-control practices that emphasize extreme or rapid weight loss. To ensure safe weight-control practices, a health-care professional should identify an appropriate competition weight and specify rates and limits of allowable weight loss for each wrestler. In addition, coaches and athletes should be trained in proper weight-control strategies and work collaboratively with a health-care professional to develop and monitor a weight-control regimen. Use of intentional dehydration to lose weight should be prohibited. To monitor compliance, a practical test to assess hydration status should be explored and employed. In addition, existing surveillance systems should be strengthened to evaluate effectiveness in preventing athletic injuries, illnesses (e.g., hyperthermia and dehydration), and deaths among the 400,000 wrestlers who participate annually in the United States (10). Because wrestlers have traditionally used dehydration as a means to lose weight, vigorous efforts will be necessary to ensure compliance with rules and guidelines designed to reduce health risks and the potential for death.

References

  1. Mueller FO, Cantu RC. National Center for Catastrophic Sports Injury Research: fourteenth annual report -- Fall 1982-Spring 1996. Chapel Hill, North Carolina: National Center for Catastrophic Sports Injury Research, 1996.

  2. Oppliger RA, Case HS, Horswill CA, Landry GL, Shelter AC. American College of Sports Medicine position statement: weight-loss in wrestlers {Review}. Med Sci Sports Exerc 1996;28:ix-xii.

  3. Horswill CA. Applied physiology of amateur wrestling. Sports Med 1992;14:114-43.

  4. Scott JR, Horswill CA, Dick RW. Acute weight gain in collegiate wrestlers following a tournament weigh-in. Med Sci Sports Exerc 1994;26:1181-5.

  5. Steen SN, Brownell KD. Patterns of weight loss and regain in wrestlers: has the tradition changed? Med Sci Sports Exerc 1990;22:762-8.

  6. Sawka MN, Young AJ, Francesconi RP, Muza SR, Pandolf KB. Thermoregulatory and blood responses during exercise at graded hypohydration levels. J Appl Physiol 1985;59:1394-401.

  7. Knochel JP. Catastrophic medical events with exhaustive exercise: "white collar rhabdomyolysis." Kidney Int 1990;38:709-19.

  8. National Collegiate Athletic Association. NCAA sports medicine handbook. 9th ed. Overland Park, Kansas: National Collegiate Athletic Association, 1997.

  9. National Collegiate Athletic Association. Immediate wrestling rules changes on weight {Memorandum}. Overland Park, Kansas: National Collegiate Athletic Association, January 13, 1998.

  10. USA Wrestling. Wrestling demographic profile {Memorandum}. Colorado Springs, Colorado: USA Wrestling, February 3, 1998.




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